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HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 218 LACY STREET 10/13/2020 TOWN OF NORTH ANDOVER Community & Economic Development HEALTH DEPARTMENT 120 Main Street NORTH ANDOVER,MASSAC14USETTS 01845 978.688.9540—Phone 978.688.9542—FAX E-MAIL:healthdept@northandoverma.gov WEBSITE:htW://www.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM RECEIVED } Date of Submission: July 17, 2019 TOfNO� � mpg Site Location:218 Lacy Street Engineer:John D. Sullivan III, PE New Plans? Yes X $275/Plan Check#210411 (includes I"submission and one re- review only) Revised Plans?Yes $125/Plan Check# Site Evaluation Forms Included? Yes x No Local Upgrade Form Included? Yes No x Telephone#:781-854-8644 Fax#: E-mail:jacksu1153@comcast.net Homeowner Name:Troy and Heidi Moran OFFICE USE ONLY When the ission is complete (including check): ➢ 7� Date stamp plans and letter ➢ Complete and attach Receipt ➢ Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database Of,,ORTM Town of North Andover HEALTH DEPARTMENT ,SSACHUSf1 CHECK DATE: LOCATION: H/O NAME: 1171/'0_4 CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice. $ ❑ Offal(Septic)Hauler $ ❑ RecreationaI Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ j` Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ ealth Agent Initials White-Applicant Yellow-Health Pink-Treasurer